Pes Planus (Flat-foot). — Flat-foot consists in the flattening of the arch of the foot. It is usually, but not always, accompanied with proration. Lovett has described a condition in which the symptoms of flat-foot are present with the exception that the arch does not ap pear to be flattened; to this he has given the name of the "pronated foot"; as its symptoms and treatment are practically those of a mild or early stage of flat-foot, it is included under that subject.
Flat-foot most often occurs in young children and adolescents, but is also com mon in adults. It has two principal causes: general weakness and rheuma tism. There is a disproportion between the strength of the foot and the use it is subjected to.
This balance in the young is usually disturbed by the bodily weakness to which children are so often subject. The weakness of the muscles throws addi tional strain on the ligaments, and these consequently stretch and let down the arch. While some patients may exhibit evidences of trouble in other parts of the body, this is often not the case, and the flattening of the arch may be the only evidence of disease that can be detected.
In adults the weakness of the foot is due to pain lessening the efficiency of the muscular support and to the rheu matic disease of the fibrous structures lessening their ability to perform their function. Patients in moderately fair condition, both generally and in respect to the feet, may have their strength over taxed by excessive use. Thus, children working at occupations requiring them to stand continually, as weaving, will be come affected.
The importance of flat-foot in causing pain in the feet emphasized. Persist ently painful feet. especially the cases that are commonly called chronic rheu matism, will gradually be found to be due to flat-foot. This condition is treated by taking a piece of celluloid plate, three to three and one-half milli metres thick, warming it in water and fitting it to the foot. This is worn in side the shoe. This makes the most satisfactory plate that can be used. Schanz (Deutsche med. Woollen., Oct. Id, 1902).
Symptoms.—Pain and discomfort are the symptoms mast complained of. This may be located generally in the foot, it feeling tired; or it may be localized, common points being often below and in front of the inner ankle, or on the dorsum near the ankle and in the instep generally. The sole of the foot becomes flattened out instead of preserving its natural hollow form. The instep sinks, and the foot on that account looks longer than it really is. It also becomes stiff, losing its flexibility. The peronei
muscles along the outer side of the ankle are often in a state of spasm and can be felt as hard cords along the lower end of the fibula and ankle. In rheumatic cases the foot usually looks thicker than normal; this is a characteristic sign, as it shows actual disease present. Pain is marked: often it can be elicited by moderate pressure over the bones and ligaments. Pain in the heel is another characteristic sign, and pains in the soft parts are apt to be present as well as in the bones and ligaments. Another im portant sign is a sweaty condition of the feet. The age of the patient also aids in diagnosis, and a history of rheuma tism or pains in the other joints can often be elicited.
Injuries comparatively rarely cause the affection. Infantile paralysis may cause it, and, if so, other evidences of paralysis will usually be present.
Treatment. — The general health should be attended to. Diathetic dis orders—such as rheumatism—should re ceive attention. Any exciting cause— such as excessive work, the wearing of improper shoes, or anything else that may tend to produce or aggravate the conditions—should be remedied. In the young, tonics should be given to build up the general health: strychnine, the hypophosphites, codliver-oil, quinine, and iron may be given. If the patient has been too closely confined in-doors, then a more out-of-door life is to be ad vised. In endeavoring to improve the local condition it is a good plan to order the patient to rest in bed for a week or two. This eases the pain at once and the spasm of the peronei muscles sub sides. Then daily massage and manipu lation should be given. This manipu lation should have as the main purpose replacing the broken-down arch in its former normal position. To do this the forepart of the foot is grasped with one hand and rotated from the outer toward the inner side. At the same time press ure should be made with the other hand on the sole of the foot below and slightly in front of the ankle so as to press the arch up. These two movements should be repeated many times twice daily— morning and evening. The foot should also be moved backward and forward so as to unlock the tarsal bones and render the foot more flexible. When the foot has been loosened up, the arch partly re stored, and the pain gone, then the pa tient may be allowed to get out of bed. To strengthen the muscles the patient should be told to stand on the toes, rais ing the heels off the floor as far as pos sible, several times a day.